Long-term Outcomes After Macular Hole Surgery

Written by: Vlad Matei, MD

June 2020

Elhusseiny AM, Schwartz SG, Flynn HW Jr, Smiddy WE. Long-term outcomes after macular hole surgery. Ophthalmol Retina 2020;4(4):369-376.

Best-corrected visual acuity (BCVA) can continue to improve during at least the first year after pars plana vitrectomy (PPV) with internal limiting membrane (ILM) peeling for idiopathic full-thickness macular hole (MH). However, few studies report long-term outcomes from subsequent years after this surgery. The purpose of the present retrospective case series was to report the anatomic and visual outcomes at least 5 years following PPV with ILM peeling for idiopathic MH.

The authors reviewed the records of all patients who underwent PPV with ILM peeling for idiopathic MH by one surgeon between 2003-2014 at Bascom Palmer Eye Institute, and who had at least 5 years of follow-up postoperatively. Patients with non-idiopathic MHs, prior vitreoretinal surgery, eye trauma, retinal breaks or intraocular inflammation were excluded from analysis. The patients underwent a standard 3-port PPV with or without indocyanine green (ICG) staining to assist ILM peeling. Either C3F8 or SF6 gas tamponade was used, and patients were asked to adhere to face-down positioning for one week postoperatively. The presence and subsequent closure of idiopathic MH were confirmed by optical coherence tomography (OCT). BCVA was noted at intervals up to 10 years postoperatively and stratified according to various factors which could influence it.

87 eyes of 80 patients met inclusion criteria. These patients, 77% of whom were female, had a mean age of 68.9 years and a mean follow-up of 9.6 years following MH surgery. ICG was used in 25% of eyes, and 83% of eyes had C3F8 tamponade. Single-surgery anatomic success was achieved in 82/87 eyes (94%). 7 eyes (8%) suffered MH reopening at a mean of 18.1 months following the first MH surgery. The mean BCVA of eyes, reported in fractional Snellen acuity, improved from 0.20 (around 20/100) preoperatively to 0.39 (around 20/50) at 1 year postoperatively, and continued statistically significant improvements were seen from 1 to 2, from 2 to 3, and from 3 to 8 years after MH surgery, with mean BCVA 0.56 (between 20/30 and 20/40) at 8 years. Similar improvements were seen even when accounting for cataract extraction prior to or after MH surgery. Although choice of gas tamponade did not seem to influence postoperative BCVA, the following factors were associated with better long-term BCVA: 20/60 or better preoperative BCVA, no ICG use; and OCT restoration of the ellipsoid zone, restoration of the external limiting membrane, and absence of intraretinal cystoid spaces. 3 eyes (3.4%) had rhegmatogenous retinal detachment at 2 months, 3 years, and 10 years after MH surgery.

The main take-home point of this paper is that BCVA can continue to improve for several years following MH surgery, and this should be emphasized when counseling MH patients. However, this study’s lack of data on MH size and symptom duration prior to MH surgery may limit its generalizability. More details on (and images of) long-term OCT changes might have provided further insights on how BCVA continued to improve even in pseudophakic patients. Finally, information on the circumstances regarding the reopening of MH or retinal detachment years following the initial MH surgery also would have been helpful to our understanding of these rare, but serious, complications. Nonetheless, this study is important as it contains among the longest follow-up periods in the MH surgery literature.